A nurse is caring for a client who is pregnant in a provider’s office.

Relevant vital signs to help answer the questions are as follows: Medical History: 0830 Gravida 3 Para 2, 32 weeks of gestation, Allergies: Penicillin, Height: 163 cm, Weight: 78 kg, BMI: 30.6, 6 lb weight gain over the last 2 weeks.

The client reports “I have had a headache for 5 days, blurred vision, and dizziness. Tylenol does not relieve it.” The client reports swelling of their feet and fingers.

2+ pitting edema of the lower extremities noted bilaterally. Swelling of the fingers and hands noted.

Deep tendon reflexes 3+, absent clonus.

Fetal heart tones (FHT) 1. Which of the following findings should the nurse report to the provider? Select all that apply.

Visual disturbances.

Fetal heart rate.

Blood pressure.

Deep tendon reflexes.

Answer and Explanation

Correct Answer : A,C,D

Rationale for Choice A: Visual disturbances
Preeclampsia: Visual disturbances, such as blurred vision or seeing spots, can be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure and protein in the urine. It typically develops after 20 weeks of gestation and can progress rapidly.
Potential complications: If left untreated, preeclampsia can lead to seizures (eclampsia), stroke, liver and kidney failure, premature birth, and even death of the mother or baby.
Prompt reporting: Early recognition and management of preeclampsia are crucial for preventing adverse outcomes. Therefore, visual disturbances should be reported to the provider immediately to initiate further assessment and potential interventions.

Rationale for Choice B: Fetal heart rate
No indication for reporting: While monitoring fetal heart rate is essential during pregnancy, the promptness of reporting it to the provider depends on specific concerns. In this case, the fetal heart tones are documented as 1, suggesting a normal rate and rhythm. There's no immediate indication for reporting it as a concerning finding.

Rationale for Choice C: Blood pressure
Hypertension: High blood pressure is a key feature of preeclampsia. Although blood pressure readings are not provided in the scenario, the nurse should measure and report them to the provider, as hypertension is a critical finding that could necessitate further evaluation and treatment.

Rationale for Choice D: Deep tendon reflexes
Hyperreflexia: The client's deep tendon reflexes are 3+, which is considered hyperreflexia. Hyperreflexia can be a neurological sign of preeclampsia, indicating increased excitability of the nervous system. It's important to report this finding to the provider for further assessment and monitoring.

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Correct Answer is ["B","C","E"]

Explanation

Choice A:
Rh incompatibility is not directly identified through amniocentesis. Instead, it's typically assessed through blood tests that determine a woman's Rh factor and screen for Rh antibodies.
However, amniocentesis can provide information that might be relevant to Rh incompatibility, such as the fetal Rh type. If the mother is Rh-negative and the fetus is Rh-positive, there's a risk of Rh incompatibility.

Choice B:
Amniocentesis can detect neural tube defects (NTDs) like spina bifida and anencephaly.
It does this by measuring the levels of alpha-fetoprotein (AFP) in the amniotic fluid. AFP is a protein produced by the fetal liver, and elevated levels in the amniotic fluid can indicate an NTD.

Choice C:
Amniocentesis can accurately determine the fetal gender by examining the sex chromosomes present in the cells of the amniotic fluid.

Choice D:
Cephalopelvic disproportion (CPD) is a condition where the baby's head is too large to fit through the mother's pelvis. It's not diagnosed through amniocentesis.
CPD is usually suspected based on clinical findings like a slow progression of labor or a high fetal station, and it might be confirmed with imaging techniques like X-ray or ultrasound.

Choice E:
Amniocentesis is a valuable tool for diagnosing chromosomal defects, such as Down syndrome, Trisomy 18, and Trisomy 13. It does this by analyzing the chromosomes of the fetal cells present in the amniotic fluid.

A. Large amount of bright red vaginal bleeding B. Severe pain with no bleeding C. High-grade fever D. Sudden sharp pain in the lower abdomen

Correct Answer is A

Explanation

Choice A rationale:
Large amount of bright red vaginal bleeding is the cardinal sign of placenta previa. This is because the placenta is abnormally positioned low in the uterus, covering the cervix partially or completely. When the cervix starts to dilate in preparation for labor, it can detach from the uterine wall, leading to significant bleeding. The blood is typically bright red, indicating fresh bleeding, and can be painless.
Severity of bleeding: The amount of bleeding can vary from spotting to massive hemorrhage, and it may start suddenly or gradually. Even a small amount of bleeding can be a sign of placenta previa and should not be ignored.
Risks of hemorrhage: Prompt recognition and management of bleeding are crucial to prevent potentially life-threatening hemorrhage for both the mother and the fetus.

Choice B rationale:
Severe pain with no bleeding is not a typical presentation of placenta previa. While some women with placenta previa may experience mild abdominal pain or cramping, severe pain without bleeding is more suggestive of placental abruption, a condition where the placenta prematurely separates from the uterine wall.

Choice C rationale:
High-grade fever is not a direct symptom of placenta previa. However, if a woman with placenta previa develops a fever, it could indicate an infection, which can further complicate the condition and require immediate medical attention.

Choice D rationale:
Sudden sharp pain in the lower abdomen can be a sign of placental abruption but is not characteristic of placenta previa.

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is 15 weeks pregnant about to undergo amniocentesis. This test can identify which traits or problems? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

A nurse is caring for a client who is pregnant and has suspected placenta previa. Which of the following should the nurse monitor the client for?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who is at 23 weeks of gestation and will return to the facility the following week for an amniocentesis. Which of the following instructions should the nurse include?

A nurse is reinforcing nutrition teaching with a client during the first prenatal visit. Which of the following statements by the client indicates understanding of the teaching?

A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse recognizes this finding as an indication of which of the following conditions? Choice Options:

A nurse is reinforcing teaching with a client who is pregnant and has a body mass index (BMI) of 22. She asks the nurse how much weight she should gain over the course of her pregnancy. Which of the following statements is an appropriate response by the nurse?

A nurse is caring for a client who has just learned that she is pregnant. The nurse should reinforce with the client to call her provider if she experiences which of the following manifestations?

A nurse is assisting with the care of a client who is in active labor at 9 weeks of gestation. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions?

A nurse is reinforcing teaching with a client who is at weeks of gestation and scheduled for a non-stress test (NST). Which of the following statements by the client indicates a need for further teaching?